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Vivian Bullwinkel LodgeRACS ID: 7312

Approved provider: Australian Flying Corps & Royal Australian Air Force Association (WA Div) Inc

Home address: 85 Hester Avenue MERRIWA WA 6030

Following an audit we decided that this home met 44 of the 44 expected outcomes of the Accreditation Standards and would be accredited for three years until 23 May 2020.

We made our decision on 18 April 2017.

The audit was conducted on 21 March 2017 to 22 March 2017. The assessment team’s report is attached.

We will continue to monitor the performance of the home including through unannounced visits.

Most recent decision concerning performance against the Accreditation StandardsStandard 1: Management systems, staffing and organisational developmentPrinciple: Within the philosophy and level of care offered in the residential care service, management systems are responsive to the needs of care recipients, their representatives, staff and stakeholders, and the changing environment in which the service operates.

1.1 Continuous improvement Met

1.2 Regulatory compliance Met

1.3 Education and staff development Met

1.4 Comments and complaints Met

1.5 Planning and leadership Met

1.6 Human resource management Met

1.7 Inventory and equipment Met

1.8 Information systems Met

1.9 External services Met

Standard 2: Health and personal carePrinciples: Care recipients’ physical and mental health will be promoted and achieved at the optimum level in partnership between each care recipient (or his or her representative) and the health care team.




2.4 Clinical care Met

2.5 Specialised nursing care needs Met

2.6 Other health and related services Met

2.7 Medication management Met

2.8 Pain management Met

2.9 Palliative care Met

2.10 Nutrition and hydration Met

2.11 Skin care Met

2.12 Continence management Met

2.13 Behavioural management Met

2.14 Mobility, dexterity and rehabilitation Met

2.15 Oral and dental care Met

2.16 Sensory loss Met

2.17 Sleep Met

Home name: Vivian Bullwinkel Lodge Dates of audit: 21 March 2017 to 22 March 2017RACS ID: 7312 2

Standard 3: Care recipient lifestylePrinciple: Care recipients retain their personal, civic, legal and consumer rights, and are assisted to achieve active control of their own lives within the residential care services and in the community.




3.4 Emotional Support Met

3.5 Independence Met

3.6 Privacy and dignity Met

3.7 Leisure interests and activities Met

3.8 Cultural and spiritual life Met

3.9 Choice and decision-making Met

3.10 Care recipient security of tenure and responsibilities Met

Standard 4: Physical Principle: Care recipients live in a safe and comfortable environment that ensures the quality of life and welfare of care recipients, staff and visitors




4.4 Living environment Met

4.5 Occupational health and safety Met

4.6 Fire, security and other emergencies Met

4.7 Infection control Met

4.8 Catering, cleaning and laundry services Met


Audit ReportName of home: Vivian Bullwinkel Lodge

RACS ID: 7312

Approved provider: Australian Flying Corps & Royal Australian Air Force Association (WA Div) Inc

IntroductionThis is the report of a Re-accreditation Audit from 21 March 2017 to 22 March 2017 submitted to the Quality Agency.

Accredited residential aged care homes receive Australian Government subsidies to provide quality care and services to care recipients in accordance with the Accreditation Standards.

To remain accredited and continue to receive the subsidy, each home must demonstrate that it meets the Standards.

There are four Standards covering management systems, health and personal care, care recipient lifestyle, and the physical environment and there are 44 expected outcomes such as human resource management, clinical care, medication management, privacy and dignity, leisure interests, cultural and spiritual life, choice and decision-making and the living environment.

Each home applies for re-accreditation before its accreditation period expires and an assessment team visits the home to conduct an audit. The team assesses the quality of care and services at the home and reports its findings about whether the home meets or does not meet the Standards. The Quality Agency then decides whether the home has met the Standards and whether to re-accredit or not to re-accredit the home.

During a home’s period of accreditation there may be a review audit where an assessment team visits the home to reassess the quality of care and services and reports its findings about whether the home meets or does not meet the Standards.

Assessment team’s findings regarding performance against the Accreditation StandardsThe information obtained through the audit of the home indicates the home meets:

44 expected outcomes


Scope of this documentAn assessment team appointed by the Quality Agency conducted the Re-accreditation Audit from 21 March 2017 to 22 March 2017.

The audit was conducted in accordance with the Quality Agency Principles 2013 and the Accountability Principles 2014. The assessment team consisted of two registered aged care quality assessors.

The audit was against the Accreditation Standards as set out in the Quality of Care Principles 2014.

Details of homeTotal number of allocated places: 79

Number of care recipients during audit: 76

Number of care recipients receiving high care during audit: 75

Special needs catered for: Veterans.


Audit trailThe assessment team spent two days on site and gathered information from the following:

Interviews

Position title Number

Facility manager 1

Registered nurses 3

Quality and clinical governance manager 1

Care staff 9

Clinical care coordinator 1

Occupational therapist 1

Physiotherapist 1

Therapy staff 2

Administration/receptionist officer 1

Operations manager - hotel services 1

Care recipients/representatives 10

Human resource manager 1

General services staff 2

Work health and safety coordinator 1

Maintenance staff 1

Sampled documents

Document type Number

Care recipient files 9

Specialised nursing care plans 6

Medication charts 8

Medication self-administration assessments 5

External provider files 3

Personnel files 6


Other documents reviewedThe team also reviewed:

Accident, incident and hazard forms

Activity attendance lists, occupational therapy and activity program statistics

Admission checklist and case conference schedule

Assessment and care plan review schedules

Audits, surveys reports and actions

Care recipient accommodation agreement and information brochures

Clinical and monthly key indicator summary reports

Comments and complaints file

Continuous improvement plan and improvement logs

Corrective and preventative schedule and maintenance records, inspection reports and cleaning schedules

Fire equipment and systems maintenance records

Food safety records, menus and dietary preference records

Medication competency assessments for clinical and care staff, and medication and specimen fridge temperature records

Medication incidents and incident tracker

Meetings minutes, toolbox records and memoranda

Menu choices, reviews and food intake records

Observation charts including blood glucose levels, weight monitoring, bowel and bladder monitoring, vital signs and behaviour responses

Policies and procedures

Position descriptions and duty statements

Professional registrations, visa information and police certificates

Register of drugs of addiction, missed medication reports and medication order forms

Staff diaries, hand books, handover records and communication books

Staff rosters and allocation sheets

Staff training and orientation records.

ObservationsThe team observed the following:

Access to internal/external and advocacy information and secure suggestion boxes

Activity calendars displayed and activities in progress

Care recipients’ appearance and interactions between staff and care recipients

Equipment and supply storage areas, including clinical equipment and oxygen

Information displayed for care recipients, representatives and staff, including notices regarding the re-accreditation audit

Living environment and closed circuit security system

Meals and refreshment services, including staff assisting care recipients as required


Medication administration and storage

Mission, philosophy and vision statements and Charter of care recipients’ rights and responsibilities displayed

Short group observation in the activity area (level 2).


Assessment informationThis section covers information about the home’s performance against each of the expected outcomes of the Accreditation Standards.

Standard 1 – Management systems, staffing and organisational developmentPrinciple: Within the philosophy and level of care offered in the residential care services, management systems are responsive to the needs of care recipients, their representatives, staff and stakeholders, and the changing environment in which the service operates.

1.1 Continuous improvementThis expected outcome requires that “the organisation actively pursues continuous improvement”.

Team’s findingsThe home meets this expected outcome

There are systems and processes to identify improvement opportunities and monitor performance against the Accreditation Standards. A range of audits, care recipient and staff surveys, feedback forms, meetings, hazard and incident data are used to identify improvements. Feedback forms are accessed by care recipients, their representatives, staff and visitors to make suggestions and record ideas for improvement. Audit results and feedback are recorded within an electronic quality improvement register, actioned and analysed for trends and opportunities to improve systems and processes. Evaluations of improvements are undertaken by gathering feedback, undertaking audits and monitoring incident data against desired outcomes. Staff reported they are able to make suggestions and provide feedback to improve care and services. Care recipients and representatives are satisfied management acknowledge and respond to their feedback and suggestions.

Recent improvements undertaken or in progress relating to Standard 1 – Management systems, staffing and organisational development are described below.

Seeking to improve communication with care staff, the home introduced a written handover. The management team reported the written handover is tailored specifically for care staff and eliminates inclusion of clinical terminology, which not all staff may be familiar with. Additionally, the written handover better accommodates the staggered start times of care staff. We observed these were used by staff during the visit, and staff provided positive feedback about the new process.

Observing the staff and care recipient noticeboards were becoming crowded, the management team has increased the number of noticeboards. We observed the care recipients’ noticeboards were not overcrowded with information during the audit and noted staff noticeboards have a specific area allocated to training updates. The management team reported this measure has improved communication with care recipients and representatives, who have been observed referring to the boards on a more frequent basis.

1.2 Regulatory complianceThis expected outcome requires that “the organisation’s management has systems in place to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines”.


The home has systems and processes to identify and monitor compliance with relevant legislation, regulatory requirements, professional standards and guidelines across the Accreditation Standards. The organisation receives updates on legislative and regulatory


changes from peak industry bodies and other professional organisations. Staff are notified of changes via training, memoranda and displayed notifications. Regular audits are planned and undertaken to monitor compliance with legislation and regulations. There is a system to collect police certificates for volunteers, new and existing staff and, where applicable, external contractors. Care recipients and representatives have access to information regarding the Aged care complaints commissioner and were informed of the re-accreditation audit via displayed notices and individual letters.

1.3 Education and staff developmentThis expected outcome requires that “management and staff have appropriate knowledge and skills to perform their roles effectively”.


The home has processes to ensure management and staff have appropriate knowledge and skills to perform their roles effectively. New staff complete a corporate orientation and ‘buddy shifts’ in order to induct them to their role. The organisation provides a range of mandatory and elective training relevant to each role. Management monitors the ongoing skills and knowledge of staff via observations, performance appraisals and the ongoing review of incidents and clinical indicators. Staff members failing to complete mandatory training within specified timeframes are not rostered. Staff confirmed they are encouraged to attend a range of training and education to maintain their skills and knowledge. Care recipients are satisfied staff are knowledgeable and have the skills to perform their roles.

Examples of education and training related to Standard 1 – Management systems, staffing and organisational development are listed below.

Care plan system training

Comments and complaints – using external complaints mechanisms

Mandatory reporting

Team building exercises and training.

1.4 Comments and complaintsThis expected outcome requires that "each care recipient (or his or her representative) and other interested parties have access to internal and external complaints mechanisms".


Care recipients and their representatives have access to internal and external complaints mechanisms. Information regarding complaints mechanisms and advocacy services is displayed in the home and outlined in the care recipient information handbook. Feedback and complaints are able to be submitted verbally, via meetings and through the completion of feedback forms. Feedback is acknowledged, logged, actioned, collated and analysed for trends to identify opportunities for improvement. Information relating to external complaints mechanisms is accessible. Translated brochures are available to assist non-English speaking care recipients to lodge complaints. Care recipients and their representatives reported they are encouraged to make comments or raise complaints and feel their feedback is responded to in a timely manner.

1.5 Planning and leadershipThis expected outcome requires that "the organisation has documented the residential care service’s vision, values, philosophy, objectives and commitment to quality throughout the service".



The organisation’s mission, philosophy and vision statements and commitment to quality are recorded in care recipient and staff handbooks and on the provider’s website. These are also displayed in the home. All such documents and sources contain consistent content.

1.6 Human resource managementThis expected outcome requires that "there are appropriately skilled and qualified staff sufficient to ensure that services are delivered in accordance with these standards and the residential care service’s philosophy and objectives".


There are appropriately skilled and qualified staff employed at the home to ensure care and services are delivered according to care recipients’ needs. A process of recruitment and selection supports the employment and retention of appropriate staff. New permanent and relief staff are orientated and undertake an induction that outlines the home’s processes. Job descriptions and duty statements are provided upon or prior to induction to guide staff in various or multiple roles. Staff skills and knowledge are maintained through mandatory and elective training, specific to their role and care recipient needs, and currency of registered staff qualifications are monitored. Rosters and staffing allocations are reviewed and amended to support the changing needs of care recipients. Casual and agency staff are used, when necessary, to cover leave and absenteeism. Staff receive feedback on their performance via probation and planned annual reviews. Staff confirmed they are satisfied with the time allocated to complete their tasks and relief arrangements. Care recipients and representatives are satisfied with the manner in which care and services are delivered by the home.

1.7 Inventory and equipmentThis expected outcome requires that "stocks of appropriate goods and equipment for quality service delivery are available".


The home has adequate supplies of goods and equipment to enable the delivery of quality care and services. The centre manager is responsible for the ordering and control of stock to ensure sufficient supplies are available. There is a planned and responsive maintenance program, and equipment is checked, repaired, serviced or replaced by the home’s maintenance team and/or external service providers. When possible, relevant staff have input into the purchase of new equipment. Staff, care recipients and representatives are satisfied repairs occur in a timely manner and requests for goods or equipment are actioned. Care recipients and representatives reported appropriate goods and equipment are provided by the home and are available to meet the needs of care recipients.

1.8 Information systemsThis expected outcome requires that "effective information management systems are in place".


The home has an effective information management system. Policies and procedures are accessible to management and staff. These are updated as required and changes are communicated to appropriate staff. Care recipients and representatives are provided with


information within agreements, handbooks, case conferences and meetings, and newsletters. Staff have access to a variety of information sources including assessments and care plans, handovers, meetings, memoranda and noticeboards. All confidential information is stored securely and electronic information is backed-up regularly. Archived information is registered and stored securely on site. Information is received and reviewed from the collection and analysis of audits, surveys and collation of clinical data. A mandatory reporting file is maintained. Management and staff demonstrated they have access to appropriate information to allow them perform their roles. Care recipients and representatives reported they have access to information appropriate to their needs, enabling care recipients to make decisions about their lifestyle and the care received.

1.9 External servicesThis expected outcome requires that "all externally sourced services are provided in a way that meets the residential care service’s needs and service quality goals".


External contractors and services are provided in a manner that meets the home’s needs and service quality goals. The service agreement and other documents outline the expectations of the organisation relating to performance and delivery of services. The home maintains a list of contractors and preferred suppliers, and the quality of goods and service is periodically reviewed. Copies of police and insurance certificates are filed with external service agreements. Staff, care recipients and representatives are satisfied with the management of external providers and the standard of external services.


Standard 2 – Health and personal carePrinciple: Care recipients’ physical and mental health will be promoted and achieved at the optimum level in partnership between each care recipient (or his or her representative) and the health care team.



Refer to expected outcome 1.1 Continuous improvement for information about the home’s continuous improvement systems and processes.

In relation to Standard 2 – Health and personal care, staff report information and monitoring occurs related to care recipient falls, skin and pressure injuries, medication incidents, behaviour responses and unexplained absences of care recipients, and this information is collated, analysed for trends and reported at meetings. Care recipients and their representatives are invited to undertake care conferences and feedback is used to improve care and services. Care recipients and staff are satisfied the organisation uses their feedback to improve care recipients’ physical and mental health.

Examples of improvement activities completed or in progress in the last 12 months related to Standard 2 – Health and personal care are described below.

Identifying that up to 20 of the care recipients have diabetes, clinical staff have created resource boxes for staff use. Each box contains cans of lemonade and jelly babies. One resource box is contained on each level. The management team reported the creation of these resource boxes assist staff responding to hypoglycaemic episodes. This is a new initiative and has yet to be utilised and evaluated.

After a review of the continence management system at the home, the facility manager purchased continence pad holders. Previously staff accessed continence pads, as required, from a central point within the home. It is expected the implementation of the new system will enable staff to more readily identify and report when a change of size or type of continence aid is required. Evaluation of this initiative will occur in later months after sufficient data regarding continence incidents or changes to continence aids has been reviewed.

2.2 Regulatory complianceThis expected outcome requires that “the organisation’s management has systems in place to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines, about health and personal care”.


The home has systems and processes for identifying relevant legislation, regulatory requirements, professional standards and guidelines in relation to care recipients’ health and personal care. Care recipients are assessed and provided with care and services by appropriately qualified staff. The home maintains a medication system whereby medication is administered and stored safely and correctly. Professional registrations and qualifications for nursing and allied health employees are monitored and maintained for currency for all professional positions.




Management and staff have the knowledge and skills to provide appropriate health and personal care to care recipients. Refer to expected outcome 1.3 Education and staff development for an overview of the system.

Examples of education and training related to Standard 2 – Health and personal care are listed below.

Advanced care planning

Dementia care essentials

Hydration and nutrition

Medication theory

Palliative care

Wound care.

2.4 Clinical careThis expected outcome requires that “care recipients receive appropriate clinical care”.


The home’s systems and processes support care recipients to receive appropriate clinical care. Each care recipient’s immediate needs are identified and outlined in an interim care plan on moving into the home. Following a settling period, a suite of assessment tools and charts is completed by a registered nurse to identify each care recipient’s needs and preferences. A comprehensive care plan is developed following the assessment period in consultation with the care recipient and their representative that is accessible to staff when delivering care and services. Assessments and care plans are reviewed every six and twelve months, and as changes occur. Day-to-day changes are communicated at handover and toolbox meetings each day and flagged in communication books to maintain continuity of care delivery. Clinical incidents are reported and investigated, and audits are undertaken to monitor and evaluate clinical and personal care. Care recipients and their representatives are satisfied care recipients receive appropriate clinical and personal care.

2.5 Specialised nursing care needsThis expected outcome requires that “care recipients’ specialised nursing care needs are identified and met by appropriately qualified nursing staff”.


Care recipients’ specialised nursing needs are identified and met by appropriately qualified nursing staff. Registered nurses are responsible for the assessment, planning, implementation and evaluation of care recipients’ specialised nursing care needs and develop specific complex health care plans that outline needs and preferences. Enrolled nurses and competent care staff provide support and deliver care to meet specialised nursing care needs. Staff report changes in care recipients to the registered nurses and those reports are followed up. Registered nurses review care recipients’ records every seven days and refer to the general practitioner for consultation regarding specialised nursing care.


The residential care line service is utilised for further advice and support on complex care needs as required. Care recipients and representatives are satisfied care recipients’ specialised nursing needs are managed and met by qualified nursing staff.

2.6 Other health and related servicesThis expected outcome requires that “care recipients are referred to appropriate health specialists in accordance with the care recipient’s needs and preferences”.


The home refers care recipients to appropriate health specialists in accordance with the care recipients’ needs and preferences. Each care recipient’s clinical, personal and lifestyle needs and preferences are assessed when they move into the home and a comprehensive care plan developed. Registered nurses monitor and refer care recipients to the general practitioner and other health services for further reviews and input, including the in-house occupational therapist and physiotherapist and external health specialists. Recommendations regarding treatment of care from other health specialists are discussed with the care recipient’s general practitioner, incorporated into care plans and care is provided. Care recipients are supported to plan and attend outside medical and specialist appointments. Care recipients reported they are satisfied with the access to appropriate health specialists.

2.7 Medication managementThis expected outcome requires that “care recipients’ medication is managed safely and correctly”.


The home’s systems and processes ensure care recipients’ medication is managed safely and correctly. Medication is ordered and supplied by a local pharmacy that nurses and medication competent care staff administer from multi-dose blister packs as per the GP’s instructions. Each care recipient has a medication profile that contains allergies and administration instructions, with a current photo for identification. General practitioners and a clinical pharmacist regularly review care recipients’ medications. Medication incident reports are investigated and analysed further for appropriate action. Staff are provided with further training where required and audits are completed to monitor the effectiveness of the medication system. Some care recipients choose to administer their own medication and are assessed by the nurse and general practitioner as to their competence. Medications are safely stored and a register of drugs maintained as required. Care recipients and their representatives are satisfied with the way care recipients’ medication is managed.

2.8 Pain managementThis expected outcome requires that “all care recipients are as free as possible from pain”.


There are systems and processes to identify, implement and evaluate each care recipient’s pain management strategies to ensure all care recipients are as free from pain as possible. Nursing staff assess each care recipient’s pain triggers and pain relief strategies, using validated assessment tools and charts for verbal and non-verbal pain indicators every six and twelve months, or when pain changes. Care plans outline a range of individual strategies to relieve pain, including pharmacological and non-pharmacological interventions such as heat and massage therapy, repositioning, exercise, pressure care, mattresses and cushions. When ‘as required’ medication is provided, a pain chart is commenced and evaluation occurs


by the registered nurse. Monitoring of the frequency of ‘as required’ medication occurs and care recipients are referred to the general practitioner and pain specialist for review. Staff described how they identify signs of verbal and non-verbal pain and strategies used to reduce care recipients’ pain and promote comfort. Care recipients are satisfied staff respond to and provide assistance to ensure they are as free as possible from pain.

2.9 Palliative careThis expected outcome requires that “the comfort and dignity of terminally ill care recipients is maintained”.


Systems and processes at the home ensure the comfort and dignity of terminally ill care recipients. On moving into the home, care recipients and their representatives are consulted on palliative care needs and preferences and an end of life preferences assessment completed. Those care recipients that hold advanced health directives are identified and information is recorded in the comprehensive care plan. Care recipients and their representatives have the opportunity to revisit and discuss their final wishes through care conferences and when advancing to the terminal phase. A chaplain is available to provide support as appropriate. General practitioners and outside palliative services are involved in planning end of life care. Staff confirmed they have attended education on palliative care and have access to appropriate equipment as required. Care recipients and representatives reported they are confident, when required, staff would meet care recipients’ needs and maintain their comfort and dignity.

2.10 Nutrition and hydrationThis expected outcome requires that “care recipients receive adequate nourishment and hydration”.


Care recipients receive adequate nourishment and hydration. On moving into the home, each care recipient’s food and drink preferences, allergies, specialised and modified diets and drinks are collected and assessed and the information provided to the kitchen and care staff. Care recipient food and fluid intake is monitored by staff and personal preferences are accommodated to encourage enjoyment of food and drinks. Each care recipient’s body weight is monitored monthly or more frequently if clinically indicated, and those at risk of poor nutrition or hydration are provided with nourishing drinks, snacks and additional fluids. A dietician is utilised as required. An assessment of swallowing occurs and texture modified meals and thickened drinks are provided. Changes to care recipients’ swallowing and risks are screened and referrals to the general practitioner and speech pathologist occur as needed. Assistive aids and devices are available and used to support care recipients to eat and drink, and staff are provided with education to safely assist care recipients. Care recipients and representatives are satisfied care recipients receive adequate nourishment and hydration.

2.11 Skin careThis expected outcome requires that “care recipients’ skin integrity is consistent with their general health”.


The home’s systems and processes ensure care recipients’ skin integrity is consistent with their general health. Each care recipient’s skin integrity, pressure injury risk and any current


wounds are identified on moving into the home and care plans are developed that detail the interventions and equipment required to improve or maintain skin integrity. Nursing and care staff apply emollients and prescribed skin treatments and attend to care recipients nail care. Wounds are assessed and cared for by nursing staff and weekly reviews are undertaken by registered nurses, including photographs used to measure the heeling process and effectiveness of wound care. Wound consultants are used as required and a podiatrist assesses and attends to foot care. A range of specialised mattresses, cushions, protective dressings, splints and repositioning regimes assist with the maintenance of each care recipient’s skin care needs. Regular audits of skin care occur and skin injuries are monitored, analysed and trends are identified. Care recipients are satisfied with the assistance provided by staff to maintain their skin integrity.

2.12 Continence managementThis expected outcome requires that “care recipients’ continence is managed effectively”.


There are systems and processes to support care recipients’ continence to be managed effectively. On moving into the home, each care recipient’s continence needs, history and care preferences are assessed in consultation with the care recipient using a three-day urinary chart and a 14-day bowel chart. The care plan is developed and outlines assistance, toileting regimes, equipment and aids required to maintain continence. Daily bowel monitoring occurs and strategies are implemented to maintain bowel function including exercise, increase of fibre and fluid intake and aperients. Urinary tract infections are monitored and reported, and prevention strategies used to reduce the risk or frequency of infections. Staff attend training in the application of aids and continence management, and confirmed there is sufficient equipment and supplies to manage care recipients’ continence and catheter management. Care recipients are satisfied with the support provided to effectively manage their continence needs.

2.13 Behavioural managementThis expected outcome requires that “the needs of care recipients with challenging behaviours are managed effectively”.


The needs of care recipients with challenging behaviours are managed effectively. When care recipients move into the home, a seven-day monitoring chart is commenced and assessment undertaken to collect information relating to behaviours. The assessment includes triggers and interventions used to prevent or minimise the behaviour responses, and the effectiveness of those interventions are included in the care plan. The registered nurse reviews behaviour charts every seven days and the care plan is updated to reflect care recipients’ needs. Referrals to the general practitioner, specialist services and older adult mental health team occur for further investigation. Incidents of responsive behaviours are reported and investigated with strategies used to prevent further escalation including diversion, change of environment, music, engagement in meaningful activities, massage and individual walks. Staff outlined how they approach and respond to responsive behaviours while meeting the needs of care recipients. Care recipients and representatives are satisfied care recipients’ responsive behaviours are managed and they do not impact on other care recipients.

2.14 Mobility, dexterity and rehabilitationThis expected outcome requires that “optimum levels of mobility and dexterity are achieved for all care recipients”.



Each care recipient’s optimum levels of mobility and dexterity are achieved. The registered nurse, physiotherapist and occupational therapist assess each care recipient’s mobility, dexterity and level of falls risk on moving into the home and outline needs and strategies in the care plan. Where risk is identified, interventions, aids and equipment are implemented to optimise mobility and dexterity. The home provides care recipients with a range of equipment and programs to maintain mobility and dexterity including group and individual exercise, walking programs, heat therapy, massage and wax baths. Falls are reported and investigated, and care recipients are reviewed by the physiotherapist. Care recipients that experience frequent falls are further reviewed at multidisciplinary team meetings and highlighted with a ‘falling star’ in their room to flag to staff the requirement for falls prevention techniques. Care recipients and their representatives are satisfied with the way staff support care recipients to maintain their mobility, dexterity and encourage independence.

2.15 Oral and dental careThis expected outcome requires that “care recipients’ oral and dental health is maintained”.


There are systems and processes to maintain care recipients’ oral and dental health. When a care recipient moves into the home, an oral and dental assessment is conducted to identify their oral function, hygiene and dental care needs and any potential impacts on swallowing and eating. Oral and dental care interventions are recorded in care recipients’ care plans. An annual dental examination is offered to care recipients and follow-up treatment is arranged with family and visiting dentists. Sufficient stocks and supplies are maintained for oral and dental hygiene, and toothbrushes and denture cups are changed seasonally. Staff described how they support care recipients with individual oral hygiene. Care recipients and representatives are satisfied with the support provided to care recipients to maintain their oral and dental health.

2.16 Sensory lossThis expected outcome requires that “care recipients’ sensory losses are identified and managed effectively”.


Care recipients’ five senses and any related sensory loss are identified and managed effectively according to needs and preferences. The registered nurse and occupational therapist assess each care recipient’s five senses, where able, on moving into the home and information collected regarding interventions to promote vision, hearing, touch, taste and smell that is reflected in the care plan. Care recipients are assisted to access vision and hearing services as required, and are provided with a range of sensory activities such as gardening, craft and cooking. Staff gave examples of how they support care recipients with sensory loss, including cleaning and applying aids and ensuring the environment is suitable to care recipients’ needs. Care recipients and representatives are satisfied with the assistance provided by staff to manage sensory loss.

2.17 SleepThis expected outcome requires that “care recipients are able to achieve natural sleep patterns”.



There are systems and processes to enable care recipients to achieve natural sleep patterns. Sleep assessments and charts are completed and information is collected to identify sleep patterns, settling and waking routines. Interventions and personal preferences to assist care recipients establish sleep and waking routines are recorded in the care plan. Strategies to promote restful sleep are implemented that include appropriate lighting, pain management and repositioning, temperature control, warm drinks and snacks. Staff reported they assist care recipients to settle at night and ensure care recipients’ needs are met through management of continence and toileting, positioning and providing general reassurance. Care recipients are satisfied staff assist them at night if they are unable to sleep and they generally are able to get a good night’s sleep.


Standard 3 – Care recipient lifestylePrinciple: Care recipients retain their personal, civic, legal and consumer rights, and are assisted to achieve control of their own lives within the residential care service and in the community.



Refer to expected outcome 1.1 Continuous improvement for an overview of the home’s continuous improvement systems and processes.

In relation to Standard 3 – Care recipient lifestyle, care recipient and representative meetings and surveys are used to gather feedback and suggestions. Feedback and observations are regularly recorded and evaluated from lifestyle and care activities. Staff can contribute to improvements to care recipient lifestyle through feedback forms, training and networking with external health providers. The home encourages care recipients and their representatives to provide feedback and suggestions in relation to lifestyle.

Examples of improvement activities in progress or completed in the last 12 months relating to Standard 3 – Care recipient lifestyle are described below.

To increase interaction between care recipients at the home and occupants of surrounding independent units, the home is organising a plant sale day. The sale is planned for late March 2017. We observed signage promoting the sale on display at the home. The management team will monitor interactions and attendance at the event in order to evaluate the activity. Further such activities may be planned depending on the success of this event.

Acting on the suggestion of a staff member, the home has introduced pet therapy sessions. These sessions, targeting care recipients living with dementia, are planned in the afternoon as a settling activity. We reviewed feedback forms and noted staff have provided positive feedback regarding these sessions. The home has incorporated the pet therapy sessions in their ongoing therapy program.

3.2 Regulatory complianceThis expected outcome requires that “the organisation’s management has systems in place to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines, about care recipient lifestyle”.


The organisation’s management has a process to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines in relation to care recipient lifestyle. The home provides each care recipient with an agreement that outlines fees and tenure arrangements. A copy of the Charter of care recipients’ rights and responsibilities is provided to care recipients and representatives in the agreement and this is also displayed within the home. There are processes to identify and undertake reporting requirements for reportable assaults and unexplained absences. Management and staff confirmed how they identify reportable incidents and reporting requirements as per the legislation and home’s policies.




Management and staff have the knowledge and skills to provide appropriate knowledge and skills to perform their roles effectively. Refer to expected outcome 1.3 Education and staff development for an overview of the system.

Examples of education and training completed relating to Standard 3 – Care recipient lifestyle are listed below.

Awareness of care recipients’ rights

Coping with grief and loss

Planning advance health directives

Privacy and dignity

Protecting older people from abuse.

3.4 Emotional support This expected outcome requires that "each care recipient receives support in adjusting to life in the new environment and on an ongoing basis".


The home provides each care recipient with support to adjust to life in the new environment and on an ongoing basis. The facility manager meets with new care recipients either before or when moving into the home, and provides initial support and information relating to the home’s day-to-day functions. A process to familiarise and orientate new care recipients occurs by providing a copy of the activity program, and visits from staff and the chaplain to assist with adjusting to the new environment. Personal preferences are considered and collected via a ‘key to me’ profile, and care recipients can personalise their room with their own furniture and belongings. Feedback forms and surveys are used by the home to identify satisfaction with emotional support and lifestyle activities. Staff confirmed how they identify and assess care recipients that require additional emotional support and receive training in managing grief and loss. Care recipients and representatives are satisfied with the emotional support provided and are made to feel welcome at the home.

3.5 IndependenceThis expected outcome requires that "care recipients are assisted to achieve maximum independence, maintain friendships and participate in the life of the community within and outside the residential care service".


Care recipients are assisted to achieve maximum independence, maintain friendships and participate in the life of the community within and outside of the home. An assessment of each care recipient’s needs and preferences in relation to their level of independence and lifestyle choices are collected when they move into the home and support required is recorded on the care plan. A range of activities is available, memberships to community groups are encouraged and staff provide support to care recipients to maintain their physical, intellectual and social abilities. Regular bus trips, shopping trips and transport to outside


groups are planned to develop and maintain friendships and connections with the outside community and surrounding village. Staff described how they assist care recipients to maintain independence and learn new skills. Care recipients, who have motorised scooters to access the village, are assessed for safety of use by the occupational therapist. Care recipients and representatives are satisfied care recipients are assisted and encouraged to participate in the community within and outside the home and maintain friendships.

3.6 Privacy and dignityThis expected outcome requires that "each care recipient’s right to privacy, dignity and confidentiality is recognised and respected".


There are systems and processes to recognise, monitor and respect each care recipient’s right to privacy, dignity and confidentiality. Personal information is stored securely and only accessible to authorised personnel. Care recipients’ right to privacy is outlined in the agreement and handbook, provided when moving into the home. Care plans outline care recipients’ preferences and some choose to have gender specific staff deliver care. Care staff were observed to maintain the privacy and dignity of care recipients with care occurring behind closed doors, knocking before entering rooms, using preferred names and conducting handover in private offices. Accommodation is provided in single rooms with ensuite and private, quite areas are available around the home. Staff interact with care recipients in a respectful manner, change their approach when care recipients are unsettled and offer care recipients a range of choices. Care recipients reported their privacy, dignity and confidentiality are recognised and respected.

3.7 Leisure interests and activitiesThis expected outcome requires that "care recipients are encouraged and supported to participate in a wide range of interests and activities of interest to them".


Care recipients are encouraged and supported to participate in a wide range of events and activities of interest to them. Each care recipient’s personal and social history is collected via a ‘key to me’ profile and activity assessment by the occupational therapist that includes both current and past interests and preferences. A care plan is developed based on those interests that are regularly evaluated and updated. Activity programs are planned around care recipients’ needs and interests, and these are reviewed and changed according to care recipient participation and feedback provided individually, from group discussions and surveys. The activity program is offered six days a week and includes a range of cognitive, physical, sensory, cultural and social activities with trips out into the community and excursions to the local village, as well as special events. Staff engage care recipients in individual activities for those who are unable or who choose not to participate in group activities. Care recipients reported they are supported to attend activities and are satisfied with the range of activities and events available to them.

3.8 Cultural and spiritual lifeThis expected outcome requires that "individual interests, customs, beliefs and cultural and ethnic backgrounds are valued and fostered".


The individual interests, customs, beliefs, and cultural and ethnic backgrounds of care recipients are valued and fostered at the home. Each care recipient’s cultural and spiritual


backgrounds and preferences are collected when they move into the home, and care recipients are supported to maintain connections and contact with their chosen groups and exercise their customs and faiths. Cultural days and significant events are celebrated by the home and care recipients have access to Catholic and Anglican services in the chapel. Some staff interpret languages spoken by care recipients. Printed information is available in other languages and communication cards are used when required. The community visitors’ scheme can be accessed as required. Care recipients are encouraged to celebrate their backgrounds and memorial services are held for care recipients that have passed away. Care recipients and representatives are satisfied the customs, beliefs, spiritual and cultural needs of care recipients are valued and fostered.

3.9 Choice and decision-makingThis expected outcome requires that "each care recipient (or his or her representative) participates in decisions about the services the care recipient receives, and is enabled to exercise choice and control over his or her lifestyle while not infringing on the rights of other people".


There are processes to ensure care recipients and their representatives can participate in decisions and exercise choice and control over their lifestyle without infringing on the rights of others. Care recipients and representatives are consulted when care plans are developed with case conferences held to provide the care recipient and their representatives an opportunity to express their views and to participate in decisions about care, treatment and services. Feedback mechanisms are accessible and care recipients are involved in decisions and menu planning. Care recipients are assisted to exercise control over their life with choices offered relating to activities of daily living and the decision to take risks. Staff respect the care recipients’ choice not to participate in activities and events and seek ongoing feedback about activities of interest to them. Care recipients and representatives are satisfied with the opportunities care recipients have to make choices and decisions regarding their care and lifestyle.

3.10 Care recipient security of tenure and responsibilitiesThis expected outcome requires that "care recipients have secure tenure within the residential care service, and understand their rights and responsibilities".


Organisational processes ensure care recipients have secure tenure within the home and understand their rights and responsibilities. An agreement is signed by care recipients or their representatives when a care recipient moves into the home or prior to moving in. The agreement includes information regarding the security of tenure, internal and external complaints mechanisms and care recipients’ rights and responsibilities. Any change of room is implemented after consultation and agreement with care recipients or their representatives. Care recipients and representatives access guardianship/administration as required. Care recipients and representatives stated they are satisfied care recipients have security of tenure at the home.


Standard 4 – Physical environment and safe systemsPrinciple: Care recipients live in a safe and comfortable environment that ensures the quality of life and welfare of care recipients, staff and visitors.



In relation to Standard 4 – Physical environment and safe systems, management and staff undertake environmental inspections and audits and report incidents and hazards. Those reports are collated, analysed for potential trends that require actions for improvement and recorded within a quality register. Staff, care recipients and representatives are encouraged to provide feedback regarding the environment. Mandatory and toolbox training is provided to staff to maintain their skills and knowledge relating to safety. Care recipients and representatives reported they are satisfied the home provides a safe and comfortable environment and their feedback and suggestions about the living environment are considered.

Improvements undertaken or in progress in relation to Standard 4 – Physical environment and safe systems are described below.

Noticing care recipients have a preference to meet and socialise in the foyer area, the home purchased furniture specifically for this area. We observed the foyer area contains comfortable armchairs and couches available to both care recipients and guests. We noted these were used by care recipients throughout the re-accreditation audit.

Mindful of the layout of the home and having identified corridor corners offer care recipients limited views of oncoming pedestrian traffic, the home is sourcing quotes for mirrors. The management team reported, when implemented, these will be positioned high on the walls to improve vision at blind spots and thereby improve the safety of care recipients and staff.

4.2 Regulatory complianceThis expected outcome requires that “the organisation’s management has systems in place to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines, about physical environment and safe systems”.


The organisation’s management has systems to identify and ensure ongoing compliance with regulations and legislation relating to the home’s physical environment and safe systems. Staff undertake mandatory training relating to fire and emergency procedures, and external contractors undertake scheduled checks of the home’s fire systems. There is a food safety program and appropriate staff receive training relating to safe food handling. Workplace inspections are carried out, and education relating to workplace safety is provided. There are reporting mechanisms in use for accidents, incidents and hazards ensuring these are investigated and actioned in a timely manner. Staff have access to personal protective equipment, safety data sheets for chemicals used within the home and infection control outbreak guidelines. Health guidelines are followed to minimise the spread of infection.




Management and staff have the knowledge and skills to enable them to perform their roles effectively in relation to the physical environment and safe systems. For information regarding the home’s systems, refer to expected outcome 1.3 Education and staff development.

Examples of education and training completed relating to Standard 4 – Physical environment and safe systems are listed below.

Basic chemical awareness

Fire and emergency training

Infection prevention and control

Manual handling

Safe food handling.

4.4 Living environmentThis expected outcome requires that "management of the residential care service is actively working to provide a safe and comfortable environment consistent with care recipients’ care needs".


A safe and comfortable living environment is provided that enables access to clean, safe and well maintained communal areas, and indoor and outdoor areas. A program of planned and responsive cleaning and maintenance maintains the safety and comfort of the environment. The home promotes the use of minimal restraints. Inspections of the environment are regularly undertaken and replacement of equipment occurs as required. Equipment is available to meet the needs of care recipients. The environment is clutter free, and equipment is stored safely and readily available to staff. The temperature of the building is controlled to ensure care recipients’ comfort levels are maintained. Staff demonstrated practices which ensure the safety and comfort of care recipients such as monitoring and reducing noise, and the provision of warm drinks. Care recipients and representatives are satisfied the living environment is safe, clean and comfortable, and it meets care recipients’ needs.

4.5 Occupational health and safetyThis expected outcome requires that "management is actively working to provide a safe working environment that meets regulatory requirements".


Management actively works to provide a safe working environment that meets regulatory requirements. A qualified workplace safety officer is available to support onsite representatives who submit monthly reports which review the safety of the home. Occupational health and safety policies are accessible and provided to staff at orientation and reinforced through annual training. Information and outcomes of audits, inspections, incidents and hazards are also discussed at staff meetings. Staff described how they report safety concerns within the home and are satisfied the work environment is safe.


4.6 Fire, security and other emergenciesThis expected outcome requires that "management and staff are actively working to provide an environment and safe systems of work that minimise fire, security and emergency risks".


Management and staff actively work to provide an environment and safe systems of work to minimise fire, security and emergency risks. Procedures covering fire and other emergencies are available to staff, care recipients and visitors, and the home maintains an evacuation list and kit. The building is equipped with a range of fire prevention and fire-fighting equipment including extinguishers, blankets and sprinklers. Approved independent professionals conduct regular inspections and testing of fire systems. A schedule is maintained to ensure regular tagging and testing of electrical equipment is undertaken. The home has a designated smoking area for care recipients, which is monitored by a closed circuit security system. Emergency exits are clearly marked throughout the home. Staff attend fire and evacuation training and drills, and described procedures to be followed in the event of a fire or other emergencies. Care recipients and representatives reported they feel safe and secure within the home.

4.7 Infection controlThis expected outcome requires that there is "an effective infection control program".


The home has an effective infection control program. Infection control guidelines, procedures and an outbreak kit are available to staff. The centre manager holds the infection control portfolio and has strategies to track and monitor care recipients’ infections and provide early interventions. Signage, personal protective equipment and hand sanitizers are readily available to assist, reduce and respond to infection risk. The home has a food safety program, and pest control and cleaning regimes are monitored for effectiveness. Staff undertake mandatory infection control training and are knowledgeable concerning standard and additional precautions. Care recipients and representatives reported satisfaction with the home’s infection control program.

4.8 Catering, cleaning and laundry servicesThis expected outcome requires that "hospitality services are provided in a way that enhances care recipients’ quality of life and the staff’s working environment".


Hospitality services are provided in a way that enhances care recipients’ quality of life and staff working environment. Meals are prepared in an offsite kitchen and transported. Changes to the menu occur in response to care recipient surveys and feedback, and input from a dietician. Assessments and reassessments ensure dietary preferences and requirements continue to be met as care recipients’ needs change. Scheduled tasks and duties guide laundry services, and there is a labelling and sorting system to limit loss of personal items. Staff undertake cleaning in accordance with schedules and use colour-coded equipment to maximise infection control practices. Monitoring of all hospitality services occurs via feedback, audits and surveys. Care recipients, representatives and staff reported general satisfaction with hospitality services.


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